Become a patient

Your choice to better care

Welcome to Well Care Community Health, where all individuals are welcome regardless of insurance or ability to pay.

To become a new patient, please provide the following information. A doctor’s appointment cannot be made until this information is received.


Requirements


  • 1

    Proof of household income, such as: a pay stub, child support, Social Security/Disability, TANIF.

  • 2

    Picture ID, such as driver’s license.

  • 3

    List of current prescription medications. You may write these on the Patient History sheet.

  • 4

    Provide copy of insurance, Medicare or Medicaid card. (Discounted fees available to patients who qualify, based on household size and income.)


Forms


Welcome Letter

English

Spanish

Patient Registration

English

Spanish

Sliding Fee Application

English

Spanish

HIPAA Privacy

English

Spanish

Patient Survey

English

Spanish

Emergency Contact

English

Spanish

Acknowledge of Receipt

English

Spanish

Contact Form

English

Spanish